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Tuesday, September 3, 2013

A Response to Dr Gawande

Dr. Atul Gawande's article in the New Yorker, "Slow Ideas"  has been spreading like wildfire on Facebook and elsewhere in the birth world. Everyone likes his ideas about woman-to-woman communicating and grassroots movements and bringing change one woman and baby at a time.

I read the article and I had serious problems with the language, first of all, but also with the overall set of assumptions about how "we" care for women and their unborn or newborn babies. 

Here are my thoughts:

Why did Ibu Robin Lim win the CNN Hero of the Year award in 2011? 

Ibu Robin has been working for nearly twenty years in Indonesia, offering free maternity care to women who would otherwise be giving birth at home, in unsanitary conditions, and possibly without attendance. She is on excellent terms with the hospitals in her area, and has single-handedly changed the face of childbirth in Indonesia.

While the goals of the Better-Birth Project are laudable, the inconsistencies in Dr. Gawande’s approach to better childbirth practices need to be addressed. First, there are several simple facts that are misrepresented in his article (“Slow Ideas”, July 29, 2013). For example, it is simply not true that “many babies cannot take their first breath without assistance”.  About 10% of newborns need assistance with their first breath, and around 1 to 2 percent need resuscitation ("Most newly born babies are vigorous. Only about 10% require some kind of assistance and only 1% need major resuscitative measures (intubation, chest compressions, and/or medications) to survive". Textbook of Neonatal Resuscitation, 6th edition, American Academy of Pediatrics, p. 39).

Secondly, serious obstetric emergencies, such as shoulder dystocia (rare and potentially fatal, and often unpredictable), are lumped together with common phenomena such as a cord around the neck (around 30% of neonates are born through a nuchal cord). This speaks of an approach to childbirth that is steeped in the western belief that childbirth is an emergency that must be prevented.

It is this approach that will not bode well for underdeveloped countries and their attempts to save mothers’ and babies’ lives. Dr. Gawande describes an effective program: women on the ground, moving from village to village, teaching simple practices that will help to save thousands, if not millions, of lives. But why stop there? Perhaps we can reduce the “twenty-nine basic recommended practices” to just ten. Actually, these 29 practices are only part of an initiative sponsored by the World Health Organization, that is studying the efficacy of a checklist in reducing infant/maternal mortality. It is not yet recommended practice, or even yet proven to be effective . "The formal trial began in 2012 to measure the impact of the Checklist on severe maternal and newborn harm ... Data collection is expected to begin in 2013 and will continue for a period of three years. It is estimated that the study will be completed by 2016."
(http://www.who.int/patientsafety/implementation/checklists/background_document.pdf p. 6 Retrieved Sept 3, 2012).

At the end of his article, Dr Gawande suggests that what made a difference, in one particular woman's life (she was a nurse), was that the expert who was making suggestions about how she could change her approach was friendly. "She was nice." A vision of maternity care that works is a vision that certainly reduces maternal/newborn mortality and morbidity. But it must also be a vision that includes respect for women and their babies, their families, and their culture and history.
(see http://www.whiteribbonalliance.org/WRA/assets/File/Final_RMC_Charter.pdf).

I believe that Dr. Gawande’s vision must be taken one step further, and that with just a little more courage and the kind of round-the-clock dedication that I have seen at Yayasan Bumi Sehat in Indonesia, we will start to see dramatic changes in maternity care around the world. We have to reduce the fear of childbirth, and the institutionalized fear of "untrained birth attendants". We can, instead, work with what we have - integrate ten or so better practices into the TBAs practice. Create better and more efficient, low-tech tools for TBAs to carry. Integrate the technology we DO have - mobile phones are used extensively all over the African continent, for example, and find creative ways to save lives. Reduce high-tech interventions. They don't work unless the infrastructure can support them.

Turn your held beliefs on their head: It is certainly a triumph of modern medicine that we can be vaccinated against tetanus. I always keep my vaccine up to date: the old lady who lived at our house in Italy years ago died from tetanus after being pricked by a rose! It is a horrible way to die, and once a wound has become infected, it is incurable.
Newborn tetanus kills babies, every day, in many countries in the world. The tetanus bacteria enters through the umbilical cord, either from unsterile equipment or unhygienic after care.

What if we didn't cut the cord? No wound! No tetanus!!!

Let's work together to find answers to this daily tragedy: mothers and babies deserve better. 

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